Provider Demographics
NPI:1336191881
Name:JOHNSON, SUSAN PIRTLE (CRNA)
Entity Type:Individual
Prefix:MISS
First Name:SUSAN
Middle Name:PIRTLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:GRACE
Other - Last Name:PIRTLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 235022
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36123-5022
Mailing Address - Country:US
Mailing Address - Phone:334-386-2051
Mailing Address - Fax:334-396-6929
Practice Address - Street 1:2105 EAST SOUTH BLVD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116
Practice Address - Country:US
Practice Address - Phone:334-288-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1090864367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q29078Medicare UPIN